Provider Demographics
NPI:1457510604
Name:RENNER, MATTHEW EDWARD (PT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:EDWARD
Last Name:RENNER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:MATT
Other - Middle Name:
Other - Last Name:RENNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:6744 CLAYTON RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1637
Mailing Address - Country:US
Mailing Address - Phone:314-644-1978
Mailing Address - Fax:314-647-1350
Practice Address - Street 1:6744 CLAYTON RD
Practice Address - Street 2:SUITE 220
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1637
Practice Address - Country:US
Practice Address - Phone:314-644-1978
Practice Address - Fax:314-647-1350
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007008752225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO481617OtherHEALTHLINK
MO120764OtherBCBS-MO
MO120764OtherBCBS-MO